The New Cardiopulmonary Resuscitation

Historical

As early as 1543 the anatomy of the heart was described. It was determined that blowing air in the windpipe improved heart beating, and it was noted that it became sluggish and weak once blowing air was stopped.

A number of scientists and experimenters followed that era, when the oxygenation of blood was better understood.

In 1954, Drs. James Elm and Peter Safar were the first to determine that cardiopulmonary resuscitation was a sound technique in saving lives. Later, Dr Safar wrote the book and outlined the main guidelines about resuscitation.

Continuous progress followed when in 1960 a group of physicians, Jude, Kouvenhoven, and Knickerbocker at John Hopkins Hospital in Baltimore, developed the method of external cardiac massage.

The science of resuscitation as we know it today is complex and involves many factors, such as the cessation of cardiac activity, the interruption of breathing, the functions of the central nervous system, the restoration of normal functions of the organs, and a series of other factors. The immediate goal in a successful cardiac resuscitation is to reverse the effects from a cardiac standstill and the poor circulation of blood mainly to the brain as well as all vital organs.

The success rate depends greatly upon a proper utilization of time (Figure 1). Unless cardiac massage is started within three to four minutes, only a very small percentage of patients will survive.

The term cardiac resuscitation applies to that action taken to save the life of a patient whose heart has suddenly ceased to beat, when there is reasonable expectation that with prompt treatment his normal cardiac and cerebral functions can be restored for an indefinite period.

Turk, LN. III, and Glenn, WW.L: Cardiac Arrest: results of attempted cardiopulmonary resuscitation in forty-two cases, New England J. Med. 251: 795-803, 1954.

                                     

Figure 1 Cardiac massage has must start within a 4 minutes period for a successful attempt

It is of great importance that the person(s) instituting cardiac massage ought to understand exactly the anatomy, circulation, and function of the heart; also the mechanism of respiration, whereas the exchange of oxygen and carbon dioxide takes place.

Statistics show that over 350,000 persons die due to sudden cardiac arrest every year. A person who has collapsed due to cardiac arrest has very little chance of survival if left alone unless a by-stander gets involved in helping that person until the paramedics arrive.

Cardiac arrest occurs in patients with advanced coronary artery disease, the ventricle may be irritable, causing the very dangerous premature contraction which will lead to ventricular tachycardia (rapid contraction of the ventricle), ventricular fibrillation (quivering of the heart), and eventually cardiac standstill. Therefore, advanced coronary artery disease is potentially dangerous and causes sudden death even if a person suffered a heart attack. Cardiopulmonary resuscitation (CPR) if instituted at the proper time, will save the life of the victim.

Cardiac Compression

The location of the heart in the chest makes it an ideal place for the use of cardiac compression. Posterior to the heart is the spine and anterior to the heart is the sternum; therefore, the presence of these two bony structures that sandwich the heart makes it easy to squeeze it. Since the spine is in the back and cannot move greatly when pushed, the sternum is a lot more flexible, making it an ideal point for cardiac compression (Figure 2). The heart is limited in motion by the surrounding structures but is flexible enough to displace blood and establish some form of circulation when good compression is maintained.

                                

Figure 2 Cross-section showing the relationship of the heart, sternum and spine, 1= heart chambers, 2= lungs, 3= sternum, 4= spine

Although the time factor is critical in a successful cardiopulmonary resuscitation, it is very important to recognize the need to start CPR and not begin cardiac compression on just any victim that is lying unconscious. The rescuer has to establish and be convinced in his own mind that the victim is not breathing or try to gasp for air.

Time is of great importance. Do not waste any valuable time checking for a pulse. First, address your victim with a very loud voice and see if the person responds to your shouting, shake your victim hard, and keep talking to him with a loud voice to determine if he or she is unconscious.

If there’s no response, determine if your victim is breathing in a normal way, none at all, or is trying to gasp for air. If you witness a person collapse for no apparent reason and is gasping for air, you should treat that person as a victim of a sudden cardiac arrest.

Unconscious is defined as the inability to respond to sensory stimuli. An unconscious victim is a person who does not respond to noise, pain, or touch due to:

  • an obstructed airway
  • cessation of breathing
  • cessation of heart beat

Once the rescuer has established the absence of breathing, pulse, or both, CPR must start immediately. If you are alone and a phone is readily available (immediately accessible) you should call 911 or your local emergency number before beginning CPR. If you are not alone the second person should call 911 or the local emergency number and you should begin CPR, this is the most important step is to initiate a rescue team. If you are in a different country than the United States, use the method of that country. Just remember that if you have reached an unconscious victim and have established that you have to institute CPR, you are capable of saving his/her life.

The emergency operator will ask you if you are familiar with CPR and if you are familiar with cardiac compression; if not, you will be guided as to the method to be used. One thing that is very important is that time is of the essence and cannot be wasted. Next, rub the victim’s chest hard with your fist and see for any response; if there’s none, start cardiac compression immediately by pushing hard and without any delays. By compressing the heart, blood is moved to the brain and vital organs. (cardiac compression will be explained in the next few paragraphs).

The next most important step is to place the victim on their back on a firm surface so that your efforts in compressing the chest are successful. Beds do not allow maximum effectiveness during compression since you will be pushing the entire victim’s body instead of compressing the victim’s chest. If the victim is lying on a bed, drag him to the floor. Do not waste any valuable time start cardiac compression immediately until someone else arrives.

If the victim is lying on the floor, kneel beside him close to his chest. With your fingertips, feel the location of the sternum at its lower border. This last structure of the sternum is the xyphoid process (see chapter one on anatomy of the heart). Back up your fingers approximately five inches or until you reach the lower half of the sternum. Do not attempt to do any compression over the xyphoid process since the liver lies behind it and you could do substantial damage and cause internal bleeding.

Place the heel of one hand over the center of the sternum and the heel of the other hand on top of the first; you also can lock your fingers together (Figure 3). This position will give you strength in pushing the sternum. The rescuer’s two arms should be closely parallel as possible and locked at the elbows, and the shoulders should be directly over the victim’s sternum. This position is very effective, making use of your upper body weight in achieving effective cardiac compression.

                              

Figure 3 The heel of one hand should be about five inches from the xyphoid process. The heel of the other hand is placed over the first, (you can lock your fingers together) so strength is achieved for pushing. (istockphoto.com)

With firm pressure, using your upper body weight (not just your arms) push straight down on the chest at least 2 inches (approximately 5 cm) (2010 ECC new guidelines). Push hard and fast at a rate of about 100 compressions a minute. This downward and rapid thrust pushes the heart compressing it against the spine and forces blood into the body and lungs (see chapter one on anatomy of the heart). With an instant release of the hand, the chest wall will recoil to its original size, creating a negative pressure. This negative pressure will help the return of the blood into the heart (Figure 4). Cardiac compression must be regular and smoothly executed. Do not jump around and do not pause between strokes.

                    

Figure 4 A = The heart lies between the sternum and the spine and cannot be moved from side to side because of the ribs and lungs. Depressing the sternum 1 ½ to 2 inches is enough to compress the chambers of the heart, thus forcing the blood into the systemic and pulmonary circulation, 1= heart, 2= sternum, 3= spine, B = shows the heart been compressed

Continue at the rate of one hundred compressions per minute. It is important to note the following during cardiac compression:

  • Pressure is applied with the heel of the hand and not the palm;
  • Compression should be applied in the center of the sternum;
  • Do not apply any pressure on the xyphoid process of the                                    sternum; this will prevent liver damage and internal bleeding;
  • Compression should be applied downwards towards the spine and not to the side.

These points are very important in order to obtain maximum effectiveness in generating an adequate blood circulation to supply the heart, brain, and vital organs.

For most bystanders, the most common response for not performing CPR on a collapsed victim was panic. Another concern was not knowing exactly what to do, and another reason was their fright of harming the victim, or that the victim is already dead. However, many other researchers have found that bystanders are reluctant of starting mouth-to-mouth breathing on strangers from fear of contracting some form of an infectious disease. In addition, fear of legal consequences has been reported as a major factor making bystanders less likely to start CPR.

Cardiocerebral Resuscitation

Cardiocerebral resuscitation or continuous compression CPR also referred to as Hands only compression CPR as to the new 2010 ECC (emergency cardiovascular care guidelines) with no need of mouth-to-mouth breathing is a new technique to revive patients that have collapsed due to sudden cardiac arrest. Dr. Gordon A. Ewy*, director of the Sarver Heart Institute in Arizona, and his colleagues started this techniques many years ago and the results are very impressive. Dr. Ewy says, “For cardiac arrest, the term rescue breathing is actually a paradox since we now know that not only is it not helpful, but often harmful.”

Dr. Ewy notes that eliminating the need for mouth-to-mouth respiration is much more effective and increases the involvement of bystanders. The key to this technique is to circulate blood to the brain. The American Heart Association has supported this statement and instituted the new standard guidelines.

Traditional CPR guidelines called for mouth-to-mouth ventilation or respiration; however, the majority of people or those close by to a collapsed individual fear from contracting other diseases when they start mouth-to-mouth breathing. Furthermore, it has been shown that even those willing in engaging in mouth-to-mouth ventilation waste an enormous amount of time and are distracted from starting chest compression.

The study further shows that the survival rate is higher when the blood is circulated with less amount of oxygen than when it has higher amount of oxygen but poorly circulated.

It has also been shown that chest compression only resuscitation increases the survival rate for out-of-hospital cardiac arrest; however, it must be pointed out that cases such as near drowning, drug overdose, or choking, the traditional CPR guidelines must still be implemented consisting of two breaths for every thirty chest compression.

The technique of chest compression only CPR is much easier than the protocol of standard CPR. If chest compression is continuously kept up for up to three minutes, the survival rate is much better than standard CPR. In public places such as shopping malls, airplanes, where automated external defibrillators or AEDs are available, the success rate is excellent if one uses an AEDs within the first five minutes of the collapse.

If your victim has collapsed in a public place and the facility is equipped with an AED (automated external defibrillator), have someone bring it and use it on the patient. Open the box and use it as per instructions. These devices are easy to use; they are also equipped with an audio system and will instruct you on how to use it. Follow their instructions as they are given.

Therefore, cardiocerebral resuscitation or CCR consists of one major component:

  • Continuous chest compression at a rate of 100 per minute without mouth-to-mouth ventilation,

Do not delay, stop, or interrupt compressions; if you get tired, you need to find another person to take your place. Keep alternating positions until help arrives or until the victim regains consciousness.

When someone collapses, there is still plenty of oxygen in the victims blood to keep that person alive for more than ten minutes if not longer; the problem is when a heart quivers or fibrillates, it does not have the ability to move or displace blood. It is your job through cardiac compression to move and circulate blood. If you stop the compressions, the blood flow stops as well. The key is to keep the rich oxygen blood circulating to the brain.

What kinds of injury can one cause while performing cardiac compression? The answer is very simple: you cannot do more harm than the victim’s present condition; without cardiac compression, the victim’s outcome is certain death. A good cardiac compression will cause one or more ribs to fracture, the victim’s medical history is of no concern to any, and the alternative is certain death. Just continue your cardiac compressions.

When should one stop? Another simple answer: when the paramedics arrive or if they tell you to stop.

Several studies have shown that the combination of chest compression along with mouth-to-mouth breathing does not appear to offer any benefits over chest compressions only. In addition, it has been documented that the survival rate for sudden cardiac arrest has increased tremendously by continuous chest compression alone.

Whether a bystander had previous CPR training does not matter and has no effect on patient survival. Emergency dispatchers recommend chest compressions only; this technique is easy and simple for bystanders. All you have to do is find the correct area on the chest and begin your compressions immediately until emergency medical personnel arrive.

A study from the University of Arizona Sarver Heart Institute noted the following three findings:

  1. The rate of bystanders getting involved with CPR patients outside the   hospital environment increased from 28 percent to 40 percent;
  2. The rate of chest compression only CPR increased from 20 percent to    76 percent; and
  3. A significant greater percent of cardiac arrest victim survived in chest    compression only was 14 percent compared to 8 percent of standards CPR.

Benefits of Chest Compression Only CPR

  • Easier to learn
  • Do not need mouth-to-mouth breathing
  • Any person can learn and implement this technique
  • No legal issues
  • The time needed to breath during traditional CPR interrupts perfusion to the brain
  • More non-medical personnel are willing to help a collapsed victim
  • More chest compressions mean more saved lives
  • Cardiac arrest victims have better chances of surviving if their rescuers spend more time in chest compression with no interruption
  • The public is more likely to learn this new techniques for its simplicity over the traditional method of CPR

The above description of continuous compressions CPRis the new technique utilized by everyone around the globe. The technique is taught everywhere, and the public is encouraged on learning this simple method of saving lives.

One must point out at this time that the above technique is not recommended for children under the age of eight or in cases of respiratory failure, drowning, or drug overdose. The standard or conventional cardiopulmonary resuscitation should be utilized.

Conclusion

In this article we only discussed the new Cardiocerebral Cpmpression only resuscition. Let us not forget that the traditional Cardiopulmonary Resuscitation, and the Heimlich maneuver are techniques that are widely used today in hospitals as well as in many everyday situations. These three techniques have saved the lives of several thousand people that would have been otherwise dead. In the next few years, you will see a rapid augmentation in the knowledge of cardiac arrest and resuscitation, and we might see in the future that Cardiopulmonary Resuscitation, Cardiocerebral Compression, and the Heimlich maneuver becomes mandatory subjects in our schools.

Cardiopulmonary resuscitation, cardiocerebral compression, and the Heimlich maneuver, although simple in concept, require a certain amount of understanding as well as practice for a successful attempt. By no means, the reader should rely solely on the content of this article to claim to know thoroughly about the rescue techniques described.

The purpose of this article is to let the reader be aware of the importance of these techniques. Your local organizations such as the American Heart Association, Red Cross, police department, fire department, and many others do give on a regular basis complete courses in rescue techniques. I do strongly suggest contacting one of these organizations and enrolling yourself as well as your family members in these courses. It is strongly recommended that all teenagers learn the techniques since they may be the ones to save the life of an older individual.

If you enroll in one of these classes, you will be able to develop good techniques by practicing on special mannequins, and you will learn the proper way of cardiac compression, breathing, and the thrust techniques while using the Heimlich maneuver.

For those of you who have taken a course, my suggestions to you are to take a refresher course every two years since we all tend to forget or become rusty from lack of using what we have already learned. Further, the techniques of cardiopulmonary resuscitation are constantly changing and modified.

Learn more in my new book available for ordering. In addition, an eBook is available also as a download. Follow the link at;

http://www.tatepublishing.com/bookstore/book.php?w=9781613468449

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